A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Disorientation

Anorexia

Increased anxiety

Blurred vision

Answer and Explanation

The Correct Answer is A

A. Disorientation in an older adult after taking lorazepam could indicate an adverse reaction or an excessive sedative effect. It's crucial to report this immediately as it may signify an overdose or an adverse reaction to the medication. Older adults are more sensitive to the sedative effects of benzodiazepines, and disorientation can indicate potential serious side effects.

B. Anorexia (loss of appetite) is a possible side effect of lorazepam but is not typically considered an urgent or immediate concern unless it leads to severe dehydration or other complications.

C. Increased anxiety could potentially occur due to paradoxical reactions to benzodiazepines; however, it's not typically considered an urgent or immediate concern unless it's severe or distressing to the client.

D. Blurred vision is a common side effect of lorazepam and other benzodiazepines. While it should be monitored and reported, it might not be considered an urgent concern unless it's significantly affecting the client's ability to function or is accompanied by other severe symptoms.

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Correct Answer is A

Explanation

A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signsprovides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.

B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.

C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.

D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.

A. Place the bedside table within the client's reach. B. Keep the bed at a comfortable working height. C. Keep a night light on in the client's room and bathroom. D. Administer a sedative at bedtime. E. Lock the wheels on beds and wheelchairs.

Correct Answer is ["A","B","C","E"]

Explanation

A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.

B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.

C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.

D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.

E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.

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A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

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